514G.103 - DEFINITIONS.

        514G.103  DEFINITIONS.         As used in this chapter, unless the context requires otherwise:         1.  "Activities of daily living" means at least bathing,      continence, dressing, eating, toileting, and transferring.         2.  "Applicant" means either of the following:         a.  In the case of an individual long-term care insurance      policy, the person who seeks to contract for benefits.         b.  In the case of a group long-term care insurance policy,      the proposed certificate holder.         3.  "Benefit trigger" means a contractual provision in a      policy of long-term care insurance that conditions the payment of      benefits on a determination of the insured's ability to perform      activities of daily living and on cognitive impairment, or on other      conditions of the insured as specified in the policy.  For purposes      of a qualified long-term care insurance contract, "benefit      trigger" means a determination by a licensed health care      practitioner that an insured is a chronically ill individual.  For      purposes of this definition, "licensed health care practitioner"      means the same as defined in section 7702B(c)(4) of the Internal      Revenue Code.         4.  "Certificate" means any certificate issued under a group      long-term care insurance policy, which policy has been delivered or      issued for delivery in this state.         5.  "Chronically ill individual" means the same as defined in      section 7702B(c)(2) of the Internal Revenue Code.         6.  "Claim" means a request for payment of benefits under an      in-force long-term care insurance policy, regardless of whether the      benefit claimed is covered under the policy or any terms or      conditions of the policy have been met.         7.  "Cognitive impairment" means a deficiency in a person's      short-term or long-term memory; orientation as to person, place, and      time; deductive or abstract reasoning; or judgment as it relates to      safety awareness.         8.  "Commissioner" means the commissioner of insurance.         9.  "Group long-term care insurance" means a long-term care      insurance policy that is delivered or issued for delivery in this      state to any of the following:         a.  One or more employers or labor organizations, or to a      trust or to the trustee or trustees of a fund established, created,      or maintained by one or more employers or labor organizations or a      combination thereof, for the benefit of employees or former employees      or a combination thereof, or for members or former members or a      combination thereof, of the employers or labor organizations.         b.  Any professional, trade, or occupational association for      its members or former or retired members, or a combination thereof,      if the association meets both of the following requirements:         (1)  Is composed of individuals all of whom are or were actively      engaged in the same profession, trade, or occupation.         (2)  Has been maintained in good faith for purposes other than      obtaining insurance.         c. (1)  An association or associations, or to a trust or to      the trustee or trustees of a fund established, created, or maintained      for the benefit of members of one or more associations, which files      evidence with the commissioner prior to advertising, marketing, or      offering a policy within this state by the association or      associations, or their insurer, that the following organizational      requirements have been met:         (a)  At the outset, there is a minimum of one hundred members of      the association or associations.         (b)  The association or associations have been organized and      maintained in good faith for purposes other than that of obtaining      insurance.         (c)  The association or associations have been in active existence      for at least one year at the time of filing.         (d)  The association or associations have a constitution and      bylaws that require all of the following:         (i)  The association or associations have regular meetings, not      less than annually, to further the purposes of the members.         (ii)  Except for credit unions, the association or associations      collect dues or solicit contributions from members.         (iii)  The members have voting privileges and representation on a      governing board and committees.         (2)  Thirty days after the required evidentiary filings have been      made, the association or associations shall be deemed to satisfy the      organizational requirements, unless the commissioner makes a finding      that the association or associations do not satisfy those      requirements.         d.  A group other than those described in paragraphs "a"      through "c", subject to a finding by the commissioner that all of      the following are true:         (1)  The issuance of the group policy is not contrary to the best      interests of the public.         (2)  The issuance of the group policy would result in economies of      acquisition or administration.         (3)  The benefits are reasonable in relation to the premiums      charged.         10.  "Independent review entity" means a review entity      certified by the commissioner pursuant to section 514G.110,      subsection 5.         11.  "Insurer" means an entity qualified and licensed by the      insurance division to transact the business of insurance in this      state by a certificate issued pursuant to chapter 508, 512B, 514, or      514B.         12.  "Licensed health care professional" means a qualified      professional in an appropriate field for determining an insured's      functional or cognitive impairment as it relates to the insured's      specific diagnosis.  Licensed health care professionals include but      are not limited to physical therapists, occupational therapists,      neurologists, physical medicine specialists, and rehabilitation      medicine specialists.         13. a.  "Long-term care insurance" means any insurance policy      or rider advertised, marketed, offered, or designed to provide      coverage for not less than twelve consecutive months for each covered      person on an expense-incurred, indemnity, prepaid, or other basis,      for one or more necessary or medically necessary diagnostic,      preventive, therapeutic, rehabilitative, maintenance, or personal      care services that are provided in a setting other than an acute care      unit of a hospital.  "Long-term care insurance" includes group      and individual annuities and life insurance policies or riders that      directly provide or supplement long-term care insurance.  The term      also includes a policy or rider that provides for payment of benefits      based upon cognitive impairment or the loss of functional capacity.      The term also includes a qualified long-term care insurance contract.      Long-term care insurance may be issued by an insurer.         b.  "Long-term care insurance" does not include any insurance      policy that is offered primarily to provide basic Medicare supplement      coverage, basic hospital expense coverage, basic medical-surgical      expense coverage, hospital confinement indemnity coverage, major      medical expense coverage, disability income or related      asset-protection coverage, accident-only coverage, specified disease      or specified accident coverage, or limited benefit health coverage.      With regard to life insurance, "long-term care insurance" does      not include life insurance policies that accelerate the death benefit      specifically for one or more of the qualifying events of terminal      illness, medical conditions requiring extraordinary medical      intervention or permanent institutional confinement, and that provide      the option of a lump-sum payment for those benefits, where neither      the benefits nor the eligibility for the benefits is conditioned upon      the receipt of long-term care.         c.  Notwithstanding any other provision of this chapter, any      product advertised, marketed, or offered as long-term care insurance      shall be subject to the provisions of this chapter.         14.  "Policy" means any policy, contract, subscriber      agreement, rider, or endorsement delivered or issued for delivery in      this state by an insurer; fraternal benefit society; nonprofit      health, hospital, or medical service corporation; prepaid health      plan; or health maintenance organization or any similar organization.         15.  "Preexisting condition" means a condition for which      medical advice or treatment was recommended by, or received from, a      provider of health care services within six months preceding the      effective date of coverage of an individual.         16.  "Qualified long-term care insurance contract" or      "federally tax-qualified long-term care insurance contract" means      any of the following:         a.  An individual or group insurance contract that meets the      requirements of section 7702B(b) of the Internal Revenue Code, as      follows:         (1)  The only insurance protection provided under the contract is      coverage of qualified long-term care services.  A contract does not      fail to satisfy the requirements of this subparagraph because      payments are made on a per diem or other periodic basis without      regard to the expenses incurred during the period to which the      payments relate.         (2)  The contract does not pay or reimburse expenses incurred for      services or items to the extent that the expenses are reimbursable      under Title XVIII of the federal Social Security Act, as amended, or      would be reimbursable but for the application of a deductible or      coinsurance amount.  The requirements of this subparagraph do not      apply to expenses that are reimbursable under Title XVIII of the      federal Social Security Act only as a secondary payor.  A contract      does not fail to satisfy the requirements of this subparagraph      because payments are made on a per diem or other periodic basis      without regard to the expenses incurred during the period to which      the payments relate.         (3)  The contract is guaranteed renewable within the meaning of      section 7702B(b)(1)(C) of the Internal Revenue Code.         (4)  The contract does not provide for a cash surrender value or      for other money that can be paid, assigned or pledged as collateral      for a loan, or borrowed except as provided in subparagraph (5).         (5)  All refunds of premiums and all policyholder dividends or      similar accounts under the contract are to be applied as a reduction      in future premiums or to increase future benefits, except that a      refund in the event of the death of the insured or a complete      surrender or cancellation of the contract shall not exceed the      aggregate premiums paid under the contract.         (6)  The contract meets the consumer protection provisions set      forth in section 7702B(g) of the Internal Revenue Code.         b.  The portion of a life insurance contract that provides      long-term care insurance coverage by rider or as part of the contract      and that satisfies the requirements of section 7702B(b) and (e) of      the Internal Revenue Code.  
         Section History: Recent Form
         2008 Acts, ch 1175, §4         Referred to in § 514G.104, 514G.105, 514G.107, 514G.110, 514H.1